Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Sunday, July 25, 2010

Lately, I have noted an increased number of pointless aeromedical transports to our hospital. These usually come from rural areas with less than stellar crews on the ground making assessments about the patient's need for urgent evaluation.

Last week, just such a case arrived of a 20ish year old who was (according to the ground crew) "having a stroke". She had been in an argument with her boyfriend and developed tingling in her arms and legs, then couldn't feel her body, then began to 'draw up' and spasm and was 'unable' to speak, becoming unconscious.

When the helicopter crew deposited this young lady in my department, they thrust a form in front of me and said "sign here, doc". It was to certify that I deemed her transfer by air as medically appropriate. I refused to sign it.

As I discussed this with the manager of our EMS Ambulance service, I learned that this overuse practice is not only my observation, but a big enough problem that we are at risk of closing down the service because of the money that is being lost.

The cynic in me believes that a large part of the problem is that competing EMS providers are cutting costs at the detriment of another provider. For instance, if Company A has only one crew stationed in a given area, if they were to transport the patient by ground, they would have to provide backup coverage for the area while that crew is out of service. However, if they call the helicopter from Company B to carry the patient....problem solved!

Though this has been a problem for years, I have really noticed an increase in the abuse of the helicopter in the past few months. Anyone else made similar observations?

16 comments:

It's endemic, and has been since Medicare increased reimbursement rates for helicopter transport EMS about 10 years ago.

Over half of helicopter EMS patients are discharged home directly from the ED, and over 75% are discharged home in 24 hours.

Part of the problem is poorly trained ground EMS crews infected with rotoriasis, but the problem isn't limited to EMS crews. Rural ER docs are susceptible, too.

Helicopter EMS is an industry begging for federal regulation, largely exempt from the FAA regulations that govern the rest of air transportation. Industry leaders have drug their feet implementing stricter flight safety standards and equipment requirements voluntarily, and are ever closer to getting those standards, and probably even more onerous ones, shoved down their throats by the feds.

When it happens, it'll be well-deserved. Regardless of what the media and general public believe, coal miners and Alaskan king crab fishermen are not the most dangerous professions in the United States.

A close friend of mine died in a crash of a Medivac. He was the pilot. The weather wasn't that great but they were called to transport.It was for a pregnant woman ....and by the way, she really didn't require a transport, because when it didn't arrive due to the crash....she seemed to do fine without it.

My Med School got a Helo in the late 80's, nice big Jet Ranger, ahhh the competition among the Nurses to get selected for the "Flight Crew", and they all got Bright Blue Flight Suits, and Head of the Line priveleges in the hospital cafeteria, even had there own Drinking Fountains and Restrooms(it WAS Alabama).Then the Helicopter crashed on a training flight, killing both of the Pilots.The replacement Helo wasn't nearly as nice, the AC didn't work, and the new pilots looked like Goober Pyle(he's from Alabama)

When I was in the hospital all radioactive, the helicopter landing place was right outside my room's window. It sure helped pass the time but I always felt sort of conflicted about feeling happy it was landing so I had something to watch...you know, because the reason it was landing was something horrible for someone. Maybe I shouldn't have felt so bad about it?

I get a little squeamish at the idea of anything "begging for federal regulation". I simply do not think that the feds will ever improve anything with regulations...in fact, I would predict that they would make the problems worse.

I too had a good friend die in a helicopter crash during dubious weather and it was such a waste because the patient (who died too) was a stable cardiac patient.

I believe that EMS dispatch (including real-time medical control) should be more proactive in defining the medical necessity of scene responses for rural areas...especially for medical calls (years ago I remember a flight for a "stroke" which was merely a blood sugar of 30).

I also think that we err when we transport non-urgent patients by air. As you point out, the risk to the patient is not zero. Just because the helicopter was called doesn't mean they have to bring the patient if the assessment doesn't warrant.

Helicopter EMS is exempt from most FAA flight safety standards, and the industry has steadfastly refused to improve on its own.

There was a recent panel to review the safety issues, and a set of suggested improvements - night vision goggles, instrument capable birds, dual pilots, terrain avoidance systems - was promulgated. Only a few have voluntarily adopted those suggestions, and yet medical helicopters keep falling out of the sky at an alarming rate.

That Alaskan king crab fisherman comparison wasn't just hyperbole.

I look for the feds to crack down in the not-too-distant future, and like you fear, they'll probably fuck it up like a soup sandwich.

But it's not like the industry hasn't been given ample opportunity to address the problems themselves.

When the feds stop suggesting and start mandating, they can't say they didn't bring it upon themselves.

My knee-jerk, and perhaps dated, reaction to AD's post was: "Bullshit." I worked the Bering and I have worked many scary places, including helicopter work, and nothing on earth comes close, except perhaps, subsurface mining.

However, I thought about it and AD is probably right. I hate working in subsurface mining environments, because of the lack of control over your own safety. Yet, there are significant safety measures in place. Working in the Bering in the winter is insane, but you have some control. You can always back off. Having heavy nets out behind a boat, or having a crab boat loading up with ice on the traps will kill everybody onboard, but you have a choice. You can stop fishing/crabbing. You can put all hands on deck, swinging anything heavy that comes to hand to break up ice from the top of the boat. The Japanese call a boat working the Bering that pushes the limits a Ni Ju Roki, a 26; it means a boat that goes down, taking all 26 crewmen with it. However, it is rare, these days. In the 1970s and 1980s, there was still foolish pride in evidence in the fleets and folks would do anything to arrive back in port with a broom hanging from the rigging, indicating they had swept the fleet in tonnage brought home. The industry has self regulated.

The problem, as I see it, with chopper-med is that, by definition, the people involved are widely separated. All of the pilots and nurses/EMTs involved are not getting back together at the end of a season or workday and figuring out solutions amongst themselves.

In fishing villages and coal mining towns, these things get discussed amongst the participants and their families.

Unfortunately, there are also those areas where doctors, and even high ranking medical directors are highly invested in the helicopter medevac system. So invested, in fact, that even after changing protocols due to a crash that killed 3 (one of two patients survived), nothing has changed because those protocols are not really being enforced. The final line in the protocol states "by paramedic discretion" and no one ever questions that discretion. Whenever people question the validity of the system, important people with '.MD' after their name play the 'what if' game. Therefore, while protocol states that MOI is a PART of the assessment, the majority of providers are taught that MOI IS the assessment.

Sorry, this is a hot button topic for me, and one that I get scant support for given where I live and practice.

the helicopter is being used as an expensive bandaid for rural and semi rural hospitals who can not keep enough qualified docs on staff to be anything more than aid stations. it is a terrible idea but points to the real trouble, the lack enough qualified trauma docs outside the big city. wonder why?

Me, I cringe, just when I see those community transportation vans. I never noticed them before, until my business partner's wife's Mom needed to be taken to the hospital (dialysis, as I recall), 5 blocks away. I am not exagerrating, we could easily have worked out driving her, or just as easily, pushed her up the sidewalk during a break from work.

Instead, we had to have this big van pull up in front of the house regularly, with a silly protocol for how to get her to the curb (our office was in the back of a huge, old house.)

It wasn't my job to flip the driver a 50, no this was a community service. A cab would have cost $20, round-trip, including tip.

Since then, I have noticed these transport vans, everywhere. Can you imagine the cost, cummulatively, of all of these vans, in every community? I would shudder if the costs were $100 per transport, nationwide, but I will bet they more closely approach $1,000 per transport.

I could have pushed Abuela up the sidewalk for free, enjoyed myself, flirted with female doctors and nurses, and been back at the office in 20 minutes. Unless I got lucky, in which case, I may have been back to the office a bit later.

Off the wall.. but ER doc, is that a picture of your local helicopter? It looks pretty sharp.

I work in a suburban city as a firefighter/paramedic with transport times to the nearest Level I trauma center less than 20 minutes. The very few instances we call for the helicopter is typically when there is a prolonged extrication on the interstate. Granted, we pride ourselves on being able to properly assess and triage patients..

There are a lot of rural communities surrounding us that do call for the helicopter a lot.

We took our infant daughter who has a CHD to our local ER as she had been vomiting, inconsolable and not well. Her sats were in the 80's (not a big deal for her). This is a regional medical center that services an area of probably 200,000. They wanted to "chopper" her to our Children's Hospital 1 1/2 hours away. We refused. They did insist on an ambulance. When we arrived at Children's the attending told us "You could've driven up yourself you know." I said "I know. Why didn't you tell that to the ER Doctor who insisted on the ambulance?" Crazy!

No, Torie. Our helicopter isn't that nice...we couldn't afford it. I found that one on Google Images.

RML: I have two high acuity pediatric centers within a 3 hour radius of my hospital. The kids with CHD, or other chronic problems are always difficult since we don't see these issues every day and don't have a baseline on the child. I usually rely on the parent (if possible) to help me assess the difference from the baseline.

When a kid with a chronic condition becomes ill, and their baseline sat is in the 80's, they can get very sick very quickly.